drugs in sport

That’s the key message of a controversial leader in the British Journal of Sport Medicine (Br J Sports Med 2004;38:666-670) from which this article is adapted, with permission from the BMJ Publishing Group Ltd

The use of performance enhancing drugs in the modern Olympics is on record as early as the games of the third Olympiad, when Thomas Hicks won the marathon after receiving an injection of strychnine in the middle of the race(1). The first official ban on ‘stimulating substances’ by a sporting organisation was introduced by the International Amateur Athletic Federation in 1928.

Using drugs to cheat in sport is not new, but it is becoming more effective. In 1976, the East German swimming team won 11 out of 13 Olympic events, and later sued the government for giving them anabolic steroids(2). Yet despite the health risks, and despite the regulating bodies’ attempts to eliminate drugs from sport, the use of illegal substances is widely known to be rife. It hardly raises an eyebrow now when some famous athlete fails a dope test.

In 1992, Vicky Rabinowicz interviewed small groups of athletes. She found that Olympic athletes, in general, believed that most successful athletes were using banned substances(3).

Much of the writing on the use of drugs in sport is focused on this kind of anecdotal evidence. There is very little rigorous, objective evidence because the athletes are doing something that is taboo, illegal and sometimes highly dangerous. The anecdotal picture tells us that our attempts to eliminate drugs from sport have failed. In the absence of good evidence, we need an analytical argument to determine what we should do.

The cheating game

We are far from the days of amateur sporting competition. Elite athletes can earn tens of millions of dollars every year in prize money alone, and millions more in sponsorship and endorsements. The lure of success is great. But the penalties for cheating are small. A six-month or one-year ban from competition is a small penalty to pay for further years of multi-million dollar success.

Drugs are much more effective today than they were in the days of strychnine and sheep’s testicles. Studies involving the anabolic steroid androgen showed that, even in doses much lower than those used by athletes, muscular strength could be improved by 5-20%(4).

Most athletes are also relatively unlikely to ever undergo testing. The International Amateur Athletic Federation estimates that only 10-15% of participating athletes are tested in each major competition(5).

The enormous rewards for the winner, the effectiveness of the drugs, and the low rate of testing all combine to create a cheating ‘game’ that is irresistible to athletes.

Drugs such as erythropoietin (EPO) and growth hormone are natural chemicals in the body. As technology advances, drugs have become harder to detect because they mimic natural processes. In a few years, there will be many undetectable drugs. Haugen’s analysis(6) predicts the obvious: that when the risk of being caught is zero, athletes will all choose to cheat.

The recent Olympic Games in Athens were the first to follow the introduction of a global anti-doping code. From the lead-up to the games to the end of competition, 3,000 drug tests were carried out: 2,600 urine tests and 400 blood tests for the endurance enhancing drug EPO(7). From these, 23 athletes were found to have taken a banned substance – the most ever in an Olympic Games(8).

The goal of ‘cleaning up’ the sport is unattainable. Further down the track the spectre of genetic enhancement looms dark and large.

So is cheating here to stay? Drugs are against the rules. But we define the rules of sport. If we made drugs legal and freely available, there would be no cheating.

Human sport is different from sports involving other animals, such as horse or dog racing. The goal of a horse race is to find the fastest horse. Horses are lined up and flogged. The winner is the one with the best combination of biology, training and rider. Basically this is a test of biological potential. This was the old naturalistic Athenian vision of sport: find the strongest, fastest or most skilled man.

Drugs that improve our natural potential are against the spirit of this model of sport. But this is not the only view of sport. Humans are not horses or dogs. We make choices and exercise our own judgement. We choose what kind of training to use and how to run our race. We can display courage, determination and wisdom. We are not flogged by a jockey on our back but drive ourselves. It is this judgement that competitors exercise when they choose diet, training and whether to take drugs… Far from being against the spirit of sport, biological manipulation embodies the human spirit – the capacity to improve ourselves on the basis of reason and judgement.

Why musicians take drugs

Classical musicians commonly use beta blockers to control their stage fright. These drugs lower heart rate and blood pressure, reducing the physical effects of stress, and it has been shown that the quality of a musical performance is improved if the musician takes these drugs(9). Although elite classical music is arguably as competitive as elite sport, and the rewards are similar, there is no stigma attached to the use of these drugs… The competition between elite musicians has rules – you cannot mime the violin to a backing CD. But there is no rule against the use of chemical enhancements.

People do well at sport as a result of the genetic lottery that happened to deal them a winning hand… If you have one version of the ACE gene, you will be better at long-distance events. If you have another, you will be better at short-distance events. Black Africans do better at short-distance events because of biologically superior muscle type and bone structure. Sport discriminates against the genetically unfit. Sport is the province of the genetic elite (or freak).

The starkest example is the Finnish skier Eero Maentyranta. In 1964, he won three gold medals. Subsequently it was found he had a genetic mutation that meant that he ‘naturally’ had 40- 50% more red blood cells than average(10). Was it fair that he had significant advantage given to him by chance?

The ability to perform well in sporting events is determined by the ability to deliver oxygen to muscles. Oxygen is carried by red blood cells. The more red blood cells, the more oxygen you can carry. This in turn controls an athlete’s performance in aerobic exercise. EPO is a natural hormone that stimulates red blood cell production, raising the packed cell volume (PCV) – the percentage of the blood comprised of red blood cells… Athletes began injecting recombinant human EPO in the 1970s, and it was officially banned in 1985(11).

Raising the PCV too high can cause health problems. The risk of harm rapidly rises as PCV gets above 50%… At these levels, raised PCV combined with hypertension would cause a ninefold increase in stroke risk. In endurance sports, dehydration causes an athlete’s blood to thicken, further raising blood viscosity and pressure(12). What begins as a relatively low risk of stroke or heart attack can rise acutely during exercise.

There are other ways to increase the number of red blood cells that are legal. Altitude training can push the PCV to dangerous, even fatal, levels. More recently, hypoxic air machines have been used to simulate altitude training. The body responds by releasing natural EPO and growing more blood cells, so that it can absorb more oxygen with every breath.

There is no difference between elevating your blood count by altitude training, by using a hypoxic air machine or by taking EPO, but the last is illegal. Some competitors have high PCVs and an advantage by luck. Some can afford hypoxic air machines. Is this fair? Nature is not fair. Ian Thorpe has enormous feet which give him an advantage that no other swimmer can get, no matter how much they exercise. Some gymnasts are more flexible, and some basketball players are seven feet tall. By allowing everyone to take performance enhancing drugs, we level the playing field. We remove the effects of genetic inequality. Far from being unfair, allowing performance enhancement promotes equality.

Should we limit drug use in sport?

There is one limit: safety. We do not want an Olympics in which people die before, during or after competition… Rather than testing for drugs, we should focus more on health and fitness to compete. Forget testing for EPO, monitor the PCV… What matters is what is a safe concentration of growth hormone – not whether it is natural or artificial.

We should permit drugs that are safe and continue to ban and monitor drugs that are unsafe… there are of course some drugs that are harmful in themselves – for example anabolic steroids. We should focus on detecting these because they are harmful not because they enhance performance.

Far from harming athletes, paradoxically, such a proposal may protect our athletes… the current incentive is to develop undetectable drugs, with little concern for safety. If safe performance enhancement drugs were permitted, there would be greater pressure to develop safe drugs.

It should also be noted that the prohibition of a substance that is already in demand carries its own intrinsic harms.

The prohibition of alcohol in America during the 1920s led to a change in drinking habits that actually increased consumption. Driven from public bars, people began to drink at home, where the alcohol was more readily available, and the incidence of deaths due to alcoholism rose or remained stable, while they dropped widely around the world in countries without prohibition(13). Furthermore, as the quality of the alcohol was unregulated, the incidence of death from poisoned alcohol rose four-fold in five years(14).

Even when prohibition leads to a decrease in consumption, it often leads to the creation of a black market to supply the continuing demand…(15). Black markets supply a product that is by definition unregulated, meaning that the use is unregulated and the safety of the product is questionable.

The direct risks from prohibiting performance enhancing drugs in sport are similar, but probably much more pronounced. Athletes currently administer performance enhancing substances in doses that are commensurate with the amount of performance gain they wish to attain, rather than the dose that can be considered ‘safe’. The athletic elite have near unlimited funds and the goal of near unlimited performance, a framework that results in the use of extremely unsafe doses. If athletes were excluded when their bodies are unsafe for competition, this kind of direct consequence from prohibition would be reduced.

Test for health not drugs

The welfare of the athlete must be our primary concern. If a drug does not expose an athlete to excessive risk, we should allow it even if it enhances performance. We have two choices: to vainly try to turn the clock back, or to rethink who we are and what sport is and to make a new 21st century Olympics. Not a super-Olympics but a more human Olympics. Our crusade against drugs in sport has failed. Rather than fearing drugs in sport, we should embrace them.

Performance enhancement is not against the spirit of sport; it is the spirit of sport. To choose to be better is to be human. Athletes should be given this choice. Their welfare should be paramount. But taking drugs is not necessarily cheating. The legalisation of drugs in sport may be fairer and safer.